- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,400.94 / $2,400.94 / $2,400.94
| Professional | | $2,400.94 | $2,400.94 | $2,400.94 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,915.00 / $5,898.00 / $9,494.00
| Professional | | $4,915.00 | $5,898.00 | $9,494.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,102.24 / $3,975.94 / $5,453.83
| Professional | | $3,102.24 | $3,975.94 | $5,453.83 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,275.00 / $1,275.00 / $3,239.00
| Facility | | $1,275.00 | $1,275.00 | $3,239.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $3,478.20 / $5,888.86 / $9,411.60
| Professional | | $3,478.20 | $5,888.86 | $9,411.60 |